FLORIDA Advance Directive Planning for Important Health Care Decisions Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org 800/658-8898 Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO), is a national consumer engagement initiative to improve care at the end of life. It’s About How You LIVE

It’s About How You LIVE is a national community engagement campaign encouraging individuals to make informed decisions about end-of-life care and services. The campaign encourages people to: Learn about options for end-of-life services and care Implement plans to ensure wishes are honored Voice decisions to family, friends and health care providers Engage in personal or community efforts to improve end-of-life care

Note: The following is not a substitute for legal advice. While Caring Connections updates the following information and form to keep them up-to-date, changes in the underlying law can affect how the form will operate in the event you lose the ability to make decisions for yourself. If you have any questions about how the form will help ensure your wishes are carried out, or if your wishes do not seem to fit with the form, you may wish to talk to your health care provider or an attorney with experience in drafting advance directives.

Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised 2010. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden.

Using these Materials BEFORE YOU BEGIN 1. Check to be sure that you have the materials for each state in which you may receive health care. 2. These materials include:  Instructions for preparing your advance directive, please read all the instructions.  Your state-specific advance directive forms, which are the pages with the gray instruction bar on the left side. ACTION STEPS 1. You may want to photocopy or print a second set of these forms before you start so you will have a clean copy if you need to start over. 2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you through the process. 3. Talk with your family, friends, and physicians about your advance directive. Be sure the person you appoint to make decisions on your behalf understands your wishes. 4. Once the form is completed and signed, photocopy the form and give it to the person you have appointed to make decisions on your behalf, your family, friends, health care providers and/or faith leaders so that the form is available in the event of an emergency. 5. You may also want to save a copy of your form in Google Health, or another online medical records management service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning. You can read more about Google Health at http://www.caringinfo.org/googlehealth.

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Introduction to Your Florida Advance Directive This packet contains a legal document that protects your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself. You may complete Part One, Part Two, or both, depending on your advance planning needs. You must complete Part Three. Part One. The Florida Designation of Health Care Surrogate lets you name someone to make decisions about your medical care, including decisions about lifeprolonging procedures, if you can no longer speak for yourself. The designation of health care surrogate is especially useful because it appoints someone to speak for you any time you are unable to make your own medical decisions, not only at the end of life. Your health care surrogate’s powers goes into effect when your doctor determines that you are no longer able to make or communicate your health care decisions. Part Two. The Florida Living Will lets you state your wishes about health care in the event that you have an end-stage condition, are in a persistent vegetative state, or develop a terminal condition and can no longer make your own health care decisions. Your living will goes into effect when your physician determines that you have one of these conditions. Your living will also allows you to express your organ donation wishes. Part Three contains the signature and witness provisions so that your document will be effective. This form does not expressly address mental illness. If you would like to make advance care plans regarding mental illness, you should talk to your physician and an attorney about a durable power of attorney tailored to your needs.

Note: These documents will be legally binding only if the person completing them is a competent adult (at least 18 years old).

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Completing Your Florida Advance Directive Whom should I appoint as my surrogate? Your surrogate is the person you appoint to make decisions about your health care if you become unable to make those decisions yourself. Your surrogate may be a family member or a close friend whom you trust to make serious decisions. The person you name as your surrogate should clearly understand your wishes and be willing to accept the responsibility of making health care decisions for you. You can appoint a second person as your alternate surrogate. The alternate will step in if the first person you name as an surrogate is unable, unwilling, or unavailable to act for you. How do I make my Florida Advance Directive legal? The law requires that you sign your Advance Directive in the presence of two adult witnesses, who must also sign the document. If you are physically unable to sign, you may have another person sign for you in your presence and in the presence of the two witnesses. Your surrogate and alternate surrogate cannot act as witnesses to this document. At least one of your witnesses must not be your spouse or a blood relative.

Note: You do not need to notarize your Florida Advance Directive. Should I add personal instructions to my Florida Advance Directive? One of the strongest reasons for naming a surrogate is to have someone who can respond flexibly as your medical situation changes and deal with situations that you did not foresee. If you add instructions to this document it may help your surrogate carry out your wishes, but be careful that you do not unintentionally restrict your surrogate’s power to act in your best interest. In any event, be sure to talk with your surrogate about your future medical care and describe what you consider to be an acceptable “quality of life.” What if I change my mind? You can always revoke your Florida Advance Directive. State law permits you to revoke your document in the following ways: 1. through a signed and dated writing showing your intent to revoke; 2. by physically destroying the original, or having someone destroy it for you in your presence; 3. by orally expressing your intent to revoke; or 4. by executing a new Advance Directive that supersedes the older document. You should notify your health care provider and surrogate(s) to ensure that your revocation is effective.

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What other facts should I know? If you would like to give your surrogate the authority to refuse life-prolonging treatment for you in the event that you become terminally ill and incompetent while you are pregnant, you must add an instruction such as, “My surrogate has the authority to order the withholding or withdrawal of life-prolonging treatment, even if I am pregnant,” under the “Additional Instructions” section on page 2 of the form. Your spouse’s powers as surrogate will be automatically revoked If you name your spouse as your surrogate and you are divorced or your marriage is subsequently annulled. If you would like your spouse’s powers to continue in the event of a divorce or annulment, you can state this in the “Additional Instructions” section on page 2 of the form by adding an instruction such as, “The authority of my surrogate shall not be revoked by divorce or annulment of our marriage.”

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FLORIDA ADVANCE DIRECTIVE – PAGE 1 OF 5 INSTRUCTIONS

Part One. Designation of Health Care Surrogate PRINT YOUR NAME

Name: ______________________________________________________ (Last) (First) (Middle Initial) In the event that I have been determined to be incapacitated to provide informed consent for medical treatment and surgical and diagnostic procedures, I wish to designate as my surrogate for health care decisions:

PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR SURROGATE

Name: ______________________________________________________ Address:_____________________________________________________ ______________________________________ Zip Code: ____________ Phone: ______________________________________________________ If my surrogate is unwilling or unable to perform his or her duties, I wish to designate as my alternate surrogate:

PRINT THE NAME, HOME ADDRESS AND TELEPHONE NUMBER OF YOUR ALTERNATE SURROGATE

Name: ______________________________________________________ Address:_____________________________________________________ ___________________________________ Zip Code: ____________ Phone: ______________________________________________________ I fully understand that this designation will permit my designee to make health care decisions and to provide, withhold, or withdraw consent on my behalf; to apply for public benefits to defray the cost of health care; and to authorize my admission to or transfer from a health care facility.

© 2005 National Hospice and Palliative Care Organization. 2010 Revised.

When making health care decisions for me, my health care surrogate should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in Part Two (if I have filled out Part Two), my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care surrogate should make decisions for me that my health care surrogate believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options.

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FLORIDA ADVANCE DIRECTIVE - PAGE 2 OF 5 ADD OTHER INSTRUCTIONS, IF ANY, REGARDING YOUR ADVANCE CARE PLANS THESE INSTRUCTIONS CAN FURTHER ADDRESS YOUR HEALTH CARE PLANS, SUCH AS YOUR WISHES REGARDING HOSPICE TREATMENT, BUT CAN ALSO ADDRESS OTHER ADVANCE PLANNING ISSUES, SUCH AS YOUR BURIAL WISHES ATTACH ADDITIONAL PAGES IF NEEDED

Additional instructions (optional):

EXAMPLE: William A. Miller says: If I'm mentally capable of making decisions regarding my health, then

I wish to make them. IF I'm incapacitated, my guiding thoughts are:

As long as my brain function is good (or is still in an appropriate timeframe in which it can sufficiently recover -- but not to exceed one year from when I became incapacitated) AND I still have the ability

to communicate (or still can regain communication in an appropriate timeframe -- not to exceed one year from when I became incapacitated)

then I wish to be kept alive -- AS LONG AS my overall organ function remains good. I don't want to have a ridiculous number of surgeries to

be kept alive (I don't know what they might be for, but five sounds like

a fair maximum number) -- and I CERTAINLY don't want to receive any

organ transplants. If it's clear my brain and communication won't recover (in the aforementioned timeframes) then I am an organ donor

and I'd love for any of my healthy organs to benefit other persons. If my organs are shutting down, then it's time for me to meet Jesus and

go to Heaven! Thank you, God bless, and no worries! :-)

© 2005 National Hospice and Palliative Care Organization. 2010 Revised.

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FLORIDA ADVANCE DIRECTIVE – PAGE 3 OF 5 INSTRUCTIONS

Part Two. Declaration PRINT THE DATE

Declaration made this _________ day of _________________, ________, (day) (month) (year)

PRINT YOUR NAME

I, _____________________________________________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that: If at any time I am incapacitated and (initial all that apply)

INITIAL EACH THAT APPLIES

______ I have a terminal condition, or ______ I have an end-stage condition, or ______ I am in a persistent vegetative state and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain. It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

© 2005 National Hospice and Palliative Care Organization. 2010 Revised.

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FLORIDA ADVANCE DIRECTIVE - PAGE 4 OF 5

ORGAN DONATION (OPTIONAL)

ORGAN DONATION (OPTIONAL) I hereby make this anatomical gift, if medically acceptable, to take effect on death. The words and marks below indicate my desires: I give (initial one choice below): any needed organs, tissues, or eyes for the purpose of transplantation, therapy, medical research, or education;

INITIAL ONLY ONE OF THE FOUR OPTIONS

only the following organs, tissues, or eyes for the purpose of transplantation, therapy, medical research, or education:

my body for anatomical study if needed. Limitations or special wishes, if any:

IF YOU HAVE ALREADY ARRANGED TO DONATE YOUR ORGANS TO A SPECIFIC DONEE, INITIAL THIS OPTION, AND INDICATE THE DETAILS OF YOUR ARRANGEMENT HERE

I have already arranged to donate Any needed organs, tissues, or eyes, The following organs, tissues, or eyes:

to the following donee: Phone: Address: ___________________________________ Zip Code:

© 2005 National Hospice and Palliative Care Organization. 2010 Revised.

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FLORIDA ADVANCE DIRECTIVE - PAGE 5 OF 5 Part Three. Execution PRINT YOUR NAME

SIGN AND DATE THE DOCUMENT

I, _________________________________________________________ understand the full impact of this declaration, and I am emotionally and mentally competent to make this declaration. I further affirm that this designation is not being made as a condition of treatment or admission to a health care facility. Signed: ___________________________________________________ Date: _____________________________________________________ Witness 1:

Print name here (relationship in parentheses)

Signed: ______________________________________________ Address: _____________________________________________ TWO WITNESSES MUST SIGN AND PRINT THEIR ADDRESSES

_____________________________________________ Witness 2:

Print name here (relationship in parentheses)

Signed: ______________________________________________ Address: _____________________________________________ _____________________________________________ (Optional) I will notify and send a copy of this document to the following persons other than my surrogate, so they may know who my surrogate is:

OPTIONAL PRINT THE NAMES AND ADDRESSES OF THOSE WHO YOU WANT TO KEEP COPIES OF THIS DOCUMENT

Name: _____________________________________________________ Address: ___________________________________________________ ___________________________________________________ Name: _____________________________________________________ Address:____________________________________________________ ____________________________________________________

© 2005 National Hospice and Palliative Care Organization. 2010 Revised.

Courtesy of Caring Connections 1731 King St., Suite 100, Alexandria, VA 22314 www.caringinfo.org, 800/658-8898 10

You Have Filled Out Your Health Care Directive, Now What? 1. Your Florida Advance Directive is an important legal document. Keep the original signed document in a secure but accessible place. Do not put the original document in a safe deposit box or any other security box that would keep others from having access to it. 2. Give photocopies of the signed original to your surrogate and alternate surrogate, doctor(s), family, close friends, clergy, and anyone else who might become involved in your health care. If you enter a nursing home or hospital, have photocopies of your document placed in your medical records. 3. Be sure to talk to your surrogate(s), doctor(s), clergy, family, and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes. 4. You may also want to save a copy of your form in Google Health, or another online medical records management service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning. You can read more about Google Health at http://www.caringinfo.org/googlehealth. 5. If you want to make changes to your documents after they have been signed and witnessed, you must complete a new document. 6. Remember, you can always revoke your Florida document. 7. Be aware that your Florida document will not be effective in the event of a medical emergency. Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states otherwise. These directives called “prehospital medical care directives” or “do not resuscitate orders” are designed for people whose poor health gives them little chance of benefiting from CPR. These directives instruct ambulance and hospital emergency personnel not to attempt CPR if your heart or breathing should stop. Currently not all states have laws authorizing these orders. We suggest you speak to your physician if you are interested in obtaining one. Caring Connections does not distribute these forms.

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